A 69 year-old man was admitted for effort angina. He tried to treat the proximal part of RCA CTO lesion in 7 years ago, however, guidewire passage had not achieved at that time. He felt effort chest pain recently and we decided to treat this lesion.

He had a history of hypertension, dyslipidemia, and smoking with 30 pack-years. Treadmill test showed no definite ST depression. The trans-thoracic echocardiography revealed RWMA in RCA territory with mild decreased LV systolic function (EF=46%).

1. A right coronary angiogram showed TIMI 0 flow proximal portion of RCA with collateral from LAD with bridging collateral from anterograde. (Figure 1, Figure 2).
2. A left coronary angiogram showed normal.

Firstly, left coronary was inserted with a 7 Fr XB 3.5 guiding catheter and right coronary was inserted with JR4 7 Fr SH guiding catheter. Initially, by using a Coronary Micro-Guide catheter, 0.014 inch Fielder FC wire was tried into septal branch to the RCA. After crossing the septal branch, it was successfully negotiated with distal PD brach. And the wire achieved the distal part of RCA, we dilated the septal branch with small balloon, sprinter 1.25*6mm and then changed the wire to miracle 3g to pass the totally occluded site of proximal RCA (Figure 3, Figure 4).

For antegrade direction, 0.014 inch Fielder FC wire was tried, but the wire could not pass the anterograde and we decide to ballooning of distal part of CTO through the retrograde wire. And JR 4 guide was very unstable and we change the guiding cather with AL 1 ST. Using the Kaneka 2.0*15mm. However, after the balloon, the anterograde wire could not pass the CTO site and then we changed the retrograde wire to harder wire, conquest pro. After the wire change, the hard wire passed the proximal part of RCA to aorta and additionally balloon the proximal RCA (Figure 5, Figure 6, Figure 7) The crossed wire was existed to the left femoral sheath through the snare wire (Figure 8). After successfully existence of wire from left femoral artery, guiding catheter was change to JR 4 7Fr SH and wire was changed through micro catheter to standard floppy wire (BMW 0.014) (Figure 9).

We inserted directly Xience-V 2.75 * 28 mm at distal RCA to PDA, secondly 3.0 * 38 mm at distal RCA, 3.5 * 28mm at mid RCA, and finally 3.5 * 28 mm at proximal to ostial RCA. (Figure 10, Figure 11, Figure 12)

Final angiogram showed successful stent expansion without periprocedural complications. (Figure 13)